FOREMP 25

Indications

• Type 2 diabetes mellitus as monotherapy (if metformin is inappropriate)
• Type 2 diabetes mellitus in combination with insulin or other antidiabetic drugs (if existing treatment fails to achieve adequate glycaemic control)
• Symptomatic chronic heart failure

Dosage

Adults: 10 mg once daily, increased to 25 mg once daily if necessary and tolerated.

Mechanism of action

Empagliflozin inhibits the SGLT2 transporters in the proximal tubules of the kidneys. By blocking the co-transport of sodium and glucose into the blood, it increases glucosuria, leading to lower blood glucose levels. Additionally, it may offer cardiovascular benefits by mechanisms yet to be fully elucidated, including effects on myocardial sodium/hydrogen exchangers and diuretic actions.

Pharmacodynamics

Empagliflozin effectively reduces blood glucose levels through increased urinary glucose excretion, necessitating once-daily dosing due to its prolonged action. Patients should be monitored for ketoacidosis, as it can occur even in the absence of significantly elevated blood glucose. The drug also poses a risk of urogenital infections due to the elevated glucose levels in urine.

Pharmacokinetics

Empagliflozin is absorbed after oral administration, with peak plasma concentrations occurring within 1.5 hours. It has a volume of distribution of approximately 73 liters and is primarily excreted via urine. Renal function should be monitored, as impaired renal function may affect drug efficacy and safety.

Contra-indications

• Diabetic ketoacidosis
• Severe renal impairment (eGFR < 30 mL/min)
• Hypersensitivity to empagliflozin or any of the excipients

Adverse effects

• Genital infections
• Urinary tract infections
• Dehydration
• Hypotension
• Diabetic ketoacidosis (rare)
• Fournier's gangrene (necrotizing fasciitis of the genitalia)

Interactions

• Antiepileptics (unknown effect on exposure)
• Rifamycins (unknown effect on exposure)
• Insulin and insulin secretagogues (may require dose adjustments)

Precautions

• Monitor for signs of diabetic ketoacidosis, particularly in patients with risk factors
• Consider temporary interruption in patients with complicated urinary tract infections
• Caution in elderly patients due to risk of hypotension and volume depletion
• Monitor renal function periodically

Pregnancy

Empagliflozin is not recommended during pregnancy due to potential risks to the fetus. Consult a healthcare provider for alternatives.

Breast-feeding

Empagliflozin is not recommended for use while breastfeeding. The effects on a nursing infant are unknown.

Storage

Store below 30°C. Protect from moisture. Keep out of reach of children.

Formulations

• Tablets: 10 mg, 25 mg

Indications

• Management of alcohol withdrawal syndrome
• Antidote in methanol or ethylene glycol poisoning
• Used in some medical procedures as a disinfectant or antiseptic

Dosage

Children: Refer to specialist guidelines, as alcohol is not typically indicated for paediatric use and may be contraindicated.

Adults: Dosing varies widely depending on the context of use and individual factors. For alcohol withdrawal, benzodiazepines are often preferred over ethanol itself.

Mechanism of action

Ethanol primarily exerts its effects by enhancing the activity of gamma-aminobutyric acid (GABA) at the GABA-A receptor, leading to increased inhibitory neurotransmission. Additionally, it inhibits the excitatory neurotransmitter glutamate at the NMDA receptor, contributing to its depressant effects. Ethanol also influences the release of several neurotransmitters, including dopamine, which is associated with its rewarding properties.

Pharmacodynamics

Ethanol's effects are dose-dependent, resulting in relaxation, sedation, and impairment of cognitive and motor functions at moderate to high doses. At lower doses, it may produce euphoria and disinhibition. Chronic use can lead to tolerance, dependence, and alcohol use disorders, characterized by compulsive consumption despite negative consequences.

Pharmacokinetics

Ethanol is rapidly absorbed from the gastrointestinal tract, with peak blood alcohol concentrations typically occurring 30 to 90 minutes after ingestion. It is metabolized primarily in the liver by alcohol dehydrogenase and the microsomal ethanol-oxidizing system (MEOS). The elimination half-life of ethanol varies but is generally around 1 to 2 hours. Factors such as age, sex, body weight, and food intake can influence the pharmacokinetics of ethanol.

Contra-indications

• Hypersensitivity to ethanol
• Severe liver disease
• Pregnancy
• History of alcohol use disorder

Adverse effects

• Drowsiness
• Dizziness
• Nausea
• Vomiting
• Headache
• Impaired coordination
• Blackouts
• Alcohol poisoning
• Increased risk of accidents

Interactions

• CNS depressants (e.g., benzodiazepines, opioids) may enhance sedative effects
• Anticoagulants (e.g., warfarin) may have altered effects
• Disulfiram may cause unpleasant reactions when used with alcohol
• Certain antihistamines may have increased sedative effects

Precautions

• Use caution in patients with liver disease
• Monitor for signs of alcohol dependence
• Avoid consumption before driving or operating machinery
• Consider risks in patients with a history of mental health disorders

Pregnancy

Consumption of alcohol during pregnancy can lead to fetal alcohol spectrum disorders and should be avoided.

Breast-feeding

Alcohol can pass into breast milk; caution is advised and excessive consumption should be avoided.

Storage

Store in a cool, dry place away from light. Keep out of reach of children.

Formulations

• Beverage alcohol (e.g., beer, wine, spirits)
• Topical antiseptics containing ethanol
• Alcohol-based hand sanitizers

Indications

• Constipation
• Dietary fiber supplementation
• Irritable bowel syndrome
• Diverticular disease
• Weight management

Dosage

Children: Refer to appropriate guidelines for specific dosage; generally taken with adequate fluid intake.

Adults: Refer to appropriate guidelines for specific dosage; generally taken with adequate fluid intake.

Mechanism of action

Cellulose acts primarily as a bulk-forming laxative. It absorbs water in the intestines, which increases stool bulk and stimulates peristalsis, thus facilitating bowel movements. Additionally, cellulose is not digestible by human enzymes, leading to fermentation by gut bacteria, which may enhance gut health and alter gut microbiota composition.

Pharmacodynamics

Cellulose increases stool weight and frequency of bowel movements. It works by retaining water in the intestines, leading to softer stools and improved passage through the gastrointestinal tract. The bulking effect of cellulose can help alleviate constipation and promote overall digestive health. It may also play a role in cholesterol reduction and glycemic control through its effects on digestion and absorption of nutrients.

Pharmacokinetics

Cellulose is not absorbed into the bloodstream due to its indigestible nature. Instead, it passes through the gastrointestinal tract, where it adds bulk to the stool. Its fermentation by colonic bacteria produces short-chain fatty acids, which may have beneficial effects on colon health. The onset of action for cellulose as a laxative can vary but is generally within 24 to 72 hours after ingestion.

Adverse effects

• Bloating
• Flatulence
• Diarrhea
• Abdominal discomfort

Precautions

• Use with caution in patients with a history of gastrointestinal disorders.
• Monitor for potential allergic reactions in sensitive individuals.

Pregnancy

Cellulose is generally considered safe during pregnancy as it is a non-toxic, indigestible fiber.

Breast-feeding

Cellulose is also considered safe during breastfeeding; it is excreted in breast milk in negligible amounts.

Storage

Store in a cool, dry place away from direct sunlight.

Formulations

• Powder
• Capsules
• Tablets
• Granules

Indications

• Hypovolemic shock
• Severe burns
• Postoperative fluid replacement
• Sepsis
• Trauma management

Dosage

Children: Refer to established guidelines for specific dosing, as it varies based on the type of colloidal solution used and the clinical condition being treated.

Adults: Refer to established guidelines for specific dosing, as it varies based on the type of colloidal solution used and the clinical condition being treated.

Mechanism of action

Colloidal solutions work by maintaining oncotic pressure in the blood, thus helping to retain fluid within the vascular system. This is primarily due to the large molecular weight of the colloidal particles, which cannot easily pass through capillary walls. The presence of colloids in the blood helps to draw water into the circulation, increasing blood volume and improving tissue perfusion.

Pharmacodynamics

The pharmacodynamics of colloidal solutions are centered on their ability to exert osmotic pressure, which helps maintain blood volume and pressure. This effect is particularly important in conditions such as hypovolemia and shock, where fluid replacement is necessary to restore hemodynamic stability. The efficacy of colloidal solutions can vary depending on the type of colloid used, as well as the underlying clinical condition being treated.

Pharmacokinetics

Colloidal solutions are typically administered intravenously and their pharmacokinetics can vary based on the specific formulation. Generally, colloids are distributed throughout the vascular compartment and have a longer duration of action compared to crystalloids, as they remain in circulation longer. The elimination of colloids is primarily through the reticuloendothelial system, where they are metabolized or eliminated by the liver and spleen. Factors such as particle size and composition can influence their distribution and clearance.

Adverse effects

• Allergic reactions
• Injection site reactions
• Nausea
• Vomiting
• Headache
• Fever

Precautions

• Use with caution in patients with known allergies to any component of the formulation
• Monitor for signs of hypersensitivity during administration
• Consider volume overload in patients with cardiac or renal impairment

Pregnancy

The safety of colloidal solutions during pregnancy has not been established. Use only if the potential benefit justifies the potential risk to the fetus.

Breast-feeding

It is not known whether colloidal solutions are excreted in human milk. Caution should be exercised when administering to breastfeeding mothers.

Storage

Store at room temperature, protect from light, and do not freeze. Keep out of reach of children.

Formulations

• Colloidal silver
• Colloidal gold
• Colloidal iron
• Other metal colloids

Indications

• Used as a disintegrant in tablet formulations
• Enhances the bioavailability of active pharmaceutical ingredients

Dosage

Children: Refer to the specific formulation guidelines, as dosage will vary based on the active ingredient and formulation type.

Adults: Refer to the specific formulation guidelines, as dosage will vary based on the active ingredient and formulation type.

Mechanism of action

Croscarmellose sodium works by swelling and absorbing water when it comes into contact with gastrointestinal fluids. This swelling leads to the rapid disintegration of the tablet or capsule matrix, facilitating the release and absorption of the active pharmaceutical ingredients.

Pharmacodynamics

Croscarmellose sodium is classified as a superdisintegrant. Its ability to rapidly disintegrate solid dosage forms can significantly enhance the dissolution rate of the active ingredient, which is crucial for achieving therapeutic effects in a timely manner.

Pharmacokinetics

Croscarmellose sodium is not absorbed in the gastrointestinal tract and does not exert pharmacological effects in the body. It is considered non-toxic and is excreted unchanged. Its main role is as an excipient, influencing the formulation's characteristics rather than the pharmacokinetics of the active ingredients.

Precautions

• Use with caution in patients with known hypersensitivity to croscarmellose or its components.

Pregnancy

Safety in pregnancy has not been established. Use only if clearly needed.

Breast-feeding

Caution is advised when using during breastfeeding, as safety has not been established.

Storage

Store in a cool, dry place, away from moisture and heat.

Formulations

• Powder
• Granules

Indications

• Monitoring respiratory function
• Assessment of metabolic status
• Management of respiratory acidosis
• Management of respiratory alkalosis

Dosage

Children: Dosing for interventions related to carbon dioxide levels in pediatric patients should be guided by clinical protocols and the BNF for Children.

Adults: Dosing for interventions related to carbon dioxide levels is typically based on clinical assessment and individual patient needs. Refer to clinical guidelines for specific scenarios.

Mechanism of action

Carbon dioxide acts primarily as a signaling molecule in the body, influencing respiratory drive and blood pH. It is produced during cellular respiration and is a critical component of the bicarbonate buffering system, which helps maintain acid-base homeostasis. Elevated levels of CO2 in the blood stimulate ventilation in the lungs, increasing the rate of gas exchange and facilitating the removal of excess CO2.

Pharmacodynamics

The pharmacodynamic effects of dioxides, particularly carbon dioxide, are closely related to its concentration in the blood. As CO2 levels increase, it leads to respiratory acidosis, which can stimulate the respiratory centers in the brain to increase ventilation. Conversely, low levels of CO2 can cause respiratory alkalosis, potentially leading to decreased respiratory drive. CO2 also plays a role in vasodilation and can affect blood flow and pressure through its influence on smooth muscle tone.

Pharmacokinetics

Carbon dioxide is produced endogenously during metabolic processes and is transported in the bloodstream primarily in three forms: dissolved in plasma, as bicarbonate ions (HCO3-), and bound to hemoglobin. The half-life of CO2 in the bloodstream is very short due to its rapid exchange with alveolar gas in the lungs. The elimination of CO2 occurs through exhalation, making it a dynamic component of respiratory physiology.

Pregnancy

Data on the effects of dioxide during pregnancy are limited. Caution is advised due to potential risks associated with exposure.

Breast-feeding

Limited data are available regarding the excretion of dioxide in human milk. Caution is recommended.

Storage

Store in a cool, dry place, away from direct sunlight and moisture.

Indications

• Used as an excipient in pharmaceutical formulations
• Improves solubility and stability of active ingredients
• Facilitates drug absorption

Dosage

Children: Refer to specific product guidelines as hydroxypropyl is typically used as an excipient and not dosed independently.

Adults: Refer to specific product guidelines as hydroxypropyl is typically used as an excipient and not dosed independently.

Mechanism of action

Hydroxypropyl functions primarily as a solubilizing agent, which aids in the dissolution of poorly soluble drugs. It interacts with water and other solvents to improve the dispersion of pharmaceutical compounds, thereby enhancing their bioavailability. Hydroxypropyl may also facilitate the permeability of drug molecules through biological membranes, contributing to their overall efficacy.

Pharmacodynamics

The pharmacodynamics of hydroxypropyl relate to its role in improving the physicochemical properties of drug formulations. By increasing solubility and stability, hydroxypropyl can enhance the absorption of drugs administered via various routes, including oral and topical. Its non-toxic nature allows for safe incorporation into formulations, making it suitable for a wide range of applications.

Pharmacokinetics

The pharmacokinetics of hydroxypropyl have not been extensively studied as it primarily acts as an excipient rather than an active pharmaceutical ingredient. When used in formulations, it is typically not absorbed into systemic circulation in significant amounts, thereby minimizing potential systemic effects. Hydroxypropyl is generally regarded as safe when used in appropriate amounts in drug formulations.

Pregnancy

Hydroxypropyl is not classified for use during pregnancy, and its safety has not been established. Caution is advised.

Breast-feeding

There is limited information on the excretion of hydroxypropyl in human milk. Caution is advised when administering to breastfeeding women.

Storage

Store in a cool, dry place, away from light. Keep out of reach of children.

Indications

• Disinfection of skin before procedures
• Antiseptic for minor cuts and abrasions
• Surface disinfectant in healthcare settings
• Solvent for pharmaceutical preparations

Dosage

Children: For topical application, the same concentration of isopropyl alcohol may be used as for adults. Refer to specific guidelines for application in children.

Adults: For topical use, apply isopropyl alcohol to the affected area as needed. For disinfection, use 70% isopropyl alcohol for effective antimicrobial action.

Mechanism of action

Isopropyl alcohol acts primarily by denaturing proteins and dissolving lipids. This disruption of the cell membrane and protein structures in microorganisms leads to cell lysis and ultimately the death of the pathogens. It is particularly effective against enveloped viruses, as the alcohol can disrupt the lipid bilayer of the viral envelope.

Pharmacodynamics

The pharmacodynamic properties of isopropyl alcohol are largely associated with its concentration and the duration of exposure. At concentrations of 60-90%, it exhibits potent antimicrobial activity. The mechanism involves dehydration of microbial cells and denaturation of proteins, which collectively contribute to its efficacy as a disinfectant.

Pharmacokinetics

Isopropyl alcohol is readily absorbed through the skin and mucous membranes. Once absorbed, it is metabolized primarily in the liver to acetone, which is then eliminated via urine. The peak plasma concentration occurs within 30 minutes to 2 hours after exposure, and the elimination half-life ranges from 2 to 4 hours, depending on the dosage and route of administration.

Adverse effects

• Headache
• Nausea
• Dizziness
• Skin irritation
• Respiratory depression in high concentrations

Precautions

• Use with caution in patients with respiratory conditions
• Avoid contact with skin and eyes
• Ensure adequate ventilation when used in high concentrations

Pregnancy

Isopropyl alcohol should be used with caution during pregnancy. Limited data is available on its safety.

Breast-feeding

Isopropyl alcohol is not recommended during breastfeeding due to potential risks.

Storage

Store in a cool, dry place away from heat sources. Keep tightly closed.

Formulations

• Isopropyl alcohol solution (e.g., 70% isopropyl alcohol)
• Isopropyl alcohol wipes
• Isopropyl alcohol gel

Indications

• Lactose intolerance
• As a filler or excipient in pharmaceutical formulations

Dosage

Children: Refer to the BNF for Children for specific dosing information based on age and clinical context.

Adults: Refer to the BNF for specific dosing information based on clinical context.

Mechanism of action

Lactose is metabolized in the intestine by the enzyme lactase into its constituent monosaccharides, glucose and galactose. In individuals with lactase deficiency, unabsorbed lactose passes into the colon, where it is fermented by bacteria, leading to gas production and osmotic effects that contribute to diarrhea.

Pharmacodynamics

The pharmacodynamics of lactose are primarily related to its effects on gastrointestinal function. In healthy individuals, lactose is effectively broken down into glucose and galactose, which are absorbed and utilized for energy. In individuals with lactose intolerance, the unabsorbed lactose can cause osmotic diarrhea and colonic fermentation, leading to discomfort and symptoms associated with lactose intolerance.

Pharmacokinetics

Lactose is not absorbed in the gastrointestinal tract until it is hydrolyzed into glucose and galactose by lactase. The absorption of glucose and galactose occurs in the small intestine. The half-life is not applicable as lactose is not typically administered as a medication but is rather ingested as a natural component of food. Its metabolism primarily occurs in the intestine.

Adverse effects

• Bloating
• Diarrhea
• Abdominal pain
• Flatulence

Precautions

• Use with caution in patients with lactose intolerance.
• Consider potential for gastrointestinal upset in sensitive individuals.

Pregnancy

Lactose is generally considered safe for use during pregnancy. However, consult a healthcare professional for individual advice.

Breast-feeding

Lactose is safe to use while breastfeeding, as it is a natural sugar present in breast milk.

Storage

Store in a cool, dry place, away from direct sunlight.

Formulations

• Powder
• Granules
• Tablets
• Syrup

Dosage

Children: Paediatric fluid requirements should be calculated based on age, weight, and clinical condition. Refer to the guidelines in the BNF for Children for detailed recommendations.

Adults: Dosage in litres may vary depending on clinical circumstances, such as fluid resuscitation needs, maintenance fluid requirements, or medication delivery. Refer to clinical guidelines for specific scenarios.

Mechanism of action

Litres do not have a pharmacological mechanism of action as they are a unit of measurement rather than a drug. However, the administration of fluids measured in litres can influence various physiological processes, including hydration status, electrolyte balance, and overall fluid homeostasis in the body.

Pharmacodynamics

As a measurement unit, litres do not exhibit pharmacodynamics. However, the volume of fluid administered can impact the pharmacodynamics of medications that are diluted or delivered in fluid form, affecting the rate of absorption, distribution, metabolism, and excretion of drugs.

Pharmacokinetics

Litres as a unit of volume do not possess pharmacokinetic properties. The pharmacokinetics of a drug may be influenced by the volume of fluid in which it is administered, as this can affect the concentration of the drug in the bloodstream and its subsequent pharmacological effects.

Indications

• Tablet coating
• Granule coating
• Improvement of drug stability
• Taste masking
• Aesthetic enhancement of pharmaceuticals

Dosage

Children: Dosage will depend on the specific formulation and active ingredients of the medication being coated. Refer to the specific product information for guidance.

Adults: Dosage will depend on the specific formulation and active ingredients of the medication being coated. Refer to the specific product information for guidance.

Mechanism of action

Opadry functions primarily as a coating polymer that adheres to the surface of tablets or granules, creating a protective layer. This layer can control the release of the active ingredient and protect it from environmental factors such as moisture and light. The specific composition of Opadry can vary, but it typically includes film-forming agents, plasticizers, and colorants that work together to achieve the desired coating characteristics.

Pharmacodynamics

The pharmacodynamics of Opadry is largely focused on its physical and chemical properties rather than specific biological interactions. The coating alters the dissolution characteristics of the drug, potentially leading to modified release profiles. This can enhance drug bioavailability or control the release rate of the active ingredient, thereby impacting the therapeutic effect.

Pharmacokinetics

As a coating agent, Opadry itself is not absorbed into the systemic circulation and does not have pharmacokinetic properties related to absorption, distribution, metabolism, or excretion of an active pharmaceutical ingredient. Its impact on pharmacokinetics is indirect, as it affects how the active drug is released and absorbed in the gastrointestinal tract.

Pregnancy

Opadry is a film-coating agent, and specific studies on its effects during pregnancy are not well-documented. Generally, it is advisable to use medications cautiously during pregnancy. Consult a healthcare provider for guidance.

Breast-feeding

Limited data are available regarding the safety of Opadry during breastfeeding. It is recommended to consult a healthcare provider before use.

Storage

Store in a cool, dry place away from direct sunlight and moisture. Keep out of reach of children.

Formulations

• Opadry OY - a coating system for oral solid dosage forms
• Opadry II - a polymer-based coating system for tablet and capsule applications

Indications

• Potential role in bone health
• Support for connective tissue formation
• May aid in mineral metabolism

Dosage

Children: There is no established clinical dosage for silicon in paediatric populations, as it is not classified as an essential nutrient.

Adults: There is no established clinical dosage for silicon in adults, as it is not classified as an essential nutrient.

Mechanism of action

Silicon is believed to enhance the synthesis of glycosaminoglycans and collagen, which are important for the structural integrity of connective tissues. It may also influence the activity of certain enzymes involved in bone mineralization, thus playing a role in maintaining bone density and health.

Pharmacodynamics

The pharmacodynamics of silicon is not fully elucidated; however, it is thought to involve the modulation of bone metabolism and the promotion of connective tissue health. Silicon may have a synergistic effect with other minerals, such as calcium and magnesium, aiding in their utilization and metabolism in the body.

Pharmacokinetics

The pharmacokinetics of silicon is complex, as it is not absorbed through typical gastrointestinal pathways. Instead, silicon is thought to be taken up in the form of silicates and then distributed throughout the body, particularly in connective tissues. The elimination of silicon occurs primarily through renal excretion, with some variations depending on dietary intake and individual metabolism.

Pregnancy

Silicon is generally considered safe during pregnancy, as it is a naturally occurring element in the human body. However, specific recommendations regarding supplementation should be followed based on the advice of a healthcare provider.

Breast-feeding

Silicon is present in breast milk in small amounts. Its safety during breastfeeding is generally regarded as acceptable, although supplementation should be approached with caution and under medical advice.

Storage

Silicon should be stored in a cool, dry place, protected from light and moisture. Follow specific storage recommendations provided by the manufacturer if available.

Pregnancy

No specific data available, consult a healthcare professional.

Breast-feeding

No specific data available, consult a healthcare professional.

Storage

Store in a cool, dry place away from light.

Mechanism of action

The vast majority of glucose filtered through the glomerulus is reabsorbed within the proximal tubule, primarily via SGLT2 (sodium-glucose linked co-transporter-2) which is responsible for ~90% of the total glucose reabsorption within the kidneys. Na⁺/K⁺-ATPase on the basolateral membrane of proximal tubular cells utilize ATP to actively pump Na+ ions into the interstitium surrounding the tubule, establishing a Na⁺ gradient within the tubular cell. SGLT2 on the apical membrane of these cells then utilize this gradient to facilitate secondary active co-transport of both Na+ and glucose out of the filtrate, thereby reabsorbing glucose back into the blood – inhibiting this co-transport, then, allows for a marked increase in glucosuria and decrease in blood glucose levels. Empagliflozin is a potent inhibitor of renal SGLT2 transporters located in the proximal tubules of the kidneys and works to lower blood glucose levels via an increase in glucosuria. Empagliflozin also appears to exert cardiovascular benefits - specifically in the prevention of heart failure - independent of its blood glucose-lowering effects, though the exact mechanism of this benefit is not precisely understood. Several theories have been posited, including the potential inhibition of Na⁺/H⁺ exchanger (NHE) 1 in the myocardium and NHE3 in the proximal tubule, reduction of pre-load via diuretic/natriuretic effects and reduction of blood pressure, prevention of cardiac fibrosis via suppression of pro-fibrotic markers, and reduction of pro-inflammatory adipokines.

Pharmacodynamics

Empagliflozin lowers blood glucose levels by preventing glucose reabsorption in the kidneys, thereby increasing the amount of glucose excreted in the urine. It has a relatively long duration of action requiring only once-daily dosing. Patients should be monitored closely for signs and symptoms of ketoacidosis regardless of blood glucose level as empagliflozin may precipitate diabetic ketoacidosis in the absence of hyperglycemia. As its mechanism of action is contingent on the renal excretion of glucose, empagliflozin may be held in cases of acute kidney injury and/or discontinued in patients who develop chronic renal disease. The overexcretion of glucose creates a sugar-rich urogenital environment which increases the risk of urogenital infections in both male and female patients - monitor closely for signs and symptoms of developing infection.